1.	Please click Reply All to your agent and AILReinstatements@ailife.com   
2.	Type the word “Agree” at the top of this email
3.	Click Send


SIGNATURE AUTHORIZATION
AMERICAN INCOME LIFE REINSTATEMENT APPLICATION



DATE:

APPLICANT LAST NAME:

APPLICANT FIRST NAME:

OWNER'S NAME: 

AGENT NAME:

AGENT NUMBER:	


With reference to my application for the reinstatement of my insurance coverage with American 
Income Life Insurance Company (“American Income Life”) on this date, I, the above-referenced 
applicant (the “Applicant”), hereby authorize the above-referenced American Income Life agent 
(the “Agent”) to affix my signature to the reinstatement application and any attendant 
documentation requiring my signature (collectively, the “Application”) and to submit the 
Application to American Income Life for underwriting. 

I understand that by responding “Agree” to this email, I am affirmatively stating that:

•	I agree to the terms and conditions set forth in the Application and hereby evidence 
        my intent to apply for insurance coverage with American Income Life;

•	I agree that the Agent may sign the Application on my behalf in each instance in 
        which my signature is required, and that such signature shall have the same effect as 
        if I had signed the Application myself by hand; and

•	I agree that the Agent may submit the completed and signed Application to American 
        Income Life for review and processing.

This authorization pertains only to the Application and will be used for no other purpose 
than contemplated herein. American Income Life maintains physical, electronic and procedural 
safeguards to protect all nonpublic personal information from unauthorized use or improper 
access.